The American Academy of Family Physicians goes woo

One of the most frustrating aspects of so-called “complementary and alternative medicine” is how much it’s managed to bypass the scientific orientation of academic medical institutions and insinuate itself deeply into medical academia. Indeed, Dr. R. W. Donnell once quite aptly referred to this phenomenon, where wildly implausible claims with no science behind them somehow find truck in some of the oldest and most prestigious academic medical centers, as “quackademic medicine.” Therapeutic touch, reiki, acupuncture, it doesn’t matter. Somehow, much of medical academia seems to have forgotten the scientific principles that should underpin modern medicine, at least when it comes to ancient claims from prescientific times.

Unfortunately, it’s not just medical academia.

Primary care physicians are on the front lines of medical care in this country. They take care of patients, big and small, healthy and chronically ill, old and young. They are the ones patients visit when they have back pain, headache, fever, coughs, chills, and the entire panoply of symptoms that plague humankind. These symptoms can mean anything from nothing, being entirely self-limited, to impending death from cancer, and it’s up to primary care doctors figure out which is which, or at least to know when he can’t and to which specialist he needs to refer a patient. Through it all, primary care doctors manage a wide variety of diseases and conditions, from diabetes to hypertension to heart disease to any number of other problems that plague so many of us. Taking care of so many different conditions requires a wide knowledge, keen diagnostic skills, and a good bedside manner. It does not require primary care doctors to embrace woo.

Sadly, the American Academy of Family Physicians (AAFP) doesn’t see it that way.

Why do I say that? It comes from my having seen a most disturbing article posted to the AAFP website entitled New Report Details Billions Americans Spend on Complementary, Alternative Medicine: Physicians Can Benefit from Adding CAM to Their Practices, Says FP.

Noooo! Not you, too, AAFP!

Sadly, the AAFP is promoting woo:

A recently released government report (15-page PDF; About PDFs) found that U.S. adults are spending almost $34 billion a year on complementary and alternative medicine, or CAM, products and therapies, as well as on visits to CAM practitioners. And that popularity can translate into extra dollars for family physicians, says one FP.

No doubt it can. There’s no doubt that selling woo can be very, very lucrative, $34 billion a year worth of lucrative. No doubt, if a physician has no concern about scientific medicine, he could rake it in hand over fist. No doubt, if a physician has–shall we say?–situational ethics, he could dive right into that filthy lucre, if he wanted to. That doesn’t mean he should. Not so, according to this article:

There’s no reason CAM techniques and remedies can’t be incorporated into family medicine practices, says Reid Blackwelder, M.D., of Kingsport, Tenn. — especially when doing so can help many diverse patients and earn FPs added compensation.

According to Blackwelder, who practices integrative medicine, “CAM providers may not do much more than we do or can do. We can recommend or use self-help tools just as well as they can, with the extra ‘oomph’ of our medical knowledge.”

Ah, yes. “Integrative” medicine, or what I like to call “integrating” pseudoscience into science-based medicine. What frightens me, however, is how Blackwelder apparently assumes that adding the extra “oomph” of medical knowledge can somehow make a worthless “treatment” suddenly have value. Actually, Blackwelder’s medical knowledge should have told him that the vast majority of CAM therapies have no basis in science and are incredibly implausible from a scientific standpoint. But, hey, who cares? It makes money!

After listing just how much money is spent by Americans on woo, including herbs and botanicals, homeopathic products, yoga, and manipulative and body-based therapies such as chiropractic, Blackwelder starts out reasonable:

“Family doctors should recognize many patients use such approaches, and explore for them in an open and nonjudgmental way,” said Blackwelder, who is a professor and program director of the East Tennessee State University Family Physicians of Kingsport family medicine residency. He’s also a former chair of the AAFP Commission on Continuing Professional Development.

“First and foremost, family physicians can use their best tool — bedside manner,” Blackwelder said. “That is a key aspect of many alternative processes and providers,” and FPs would do well to use that empathy to connect with patients.

And, of course, there’s nothing wrong with that. We physicians should explore in open and nonjudgmental ways everything about their health history, including any CAM therapies they may be using. We should also be open and willing to offer our opinions in the aforementioned nonjudgmental manner. Moreover, physicians should work on their bedside manner. Not only is the bedside manner what so many CAM practitioners have that too many physicians do not, but that empathy and caring is what maximizes the placebo effect that so many CAM practitioners rely on. What physicians should not do is this:

In many ways, the physician-patient encounter creates a suggestible moment similar to what is done in a hypnosis session,” said Blackwelder. “Use that power!”

Family physicians can build in discussions of CAM during face-to-face office visits for specific complaints, he said, by suggesting, for example, nasal irrigation for allergies and respiratory problems; yoga relaxation breathing for insomnia and anxiety; yin yoga for back, hip and flexibility problems; journaling for grief, depression, rheumatoid arthritis and asthma; and meditation and prayer for hypertension, stress and depression.

“A suggestible moment similar to what is done in a hypnosis session”? Even if that were true, it would be profoundly unethical to take advantage of a suggestible state in that way. Think of it. In the first part of the article, it is being argued that CAM modalities can make money for family physicians. Now, Blackwelder is arguing that the physician-patient encounter provides a “suggestible” state that would allow physicians to sell their patients on CAM. Is it just me, or, putting it all together, did Blackwelder just say to take advantage of the power and trust physicians have in the physician-patient relationship in order to enrich themselves by selling CAM? No, I don’ think that’s a straw man argument at all. In context, that certainly seems to be the implication of Blackwelder’s overall argument. I don’t think it’s a strawman at all. Whether Blackwelder meant it that way when he said it, he sure as heck came off as arguing to take advantage of the trust and power physicians have in order to prescribe woo and make more money.

Worse than that, much of what he suggests has already been tested scientifically and been found not to work. For example, prayer doesn’t work for hypertension. In fact, it may even be correlated with hypertension. There’s little or no evidence for the rest of these, with the possible exception of nasal irrigation. However, as a reader has informed me, the evidence in favor of nasal irrigation is weak. Even so, note how Blackwelder coopts a science-based treatment (nasal irrigation) as being some how “alternative” or CAM. Oh, well, I suppose I should be grateful that Blackwelder refrained from suggesting homeopathy (a.k.a. The One Quackery To Rule Them All), therapeutic touch, reiki, or acupuncture.

Oh, wait. Blackwelder did advocate acupuncture. Indeed, he suggested that family docs “take a course” to learn acupuncture. Personally, I wouldn’t recommend it. I can do acupuncture. No, I haven’t taken a course, either. The reason I say that I can do acupuncture is that numerous studies have shown that it really doesn’t matter where you place the needles. So I could place the needles anywhere I wanted to, spin some imaginative name for the “meridian” I’m putting the needles in, and–voilà!–I’m an instant acupuncturist! Heck, I’ll even teach you. It’s all placebo effect. In fact, it doesn’t matter if the needles are even inserted if the patient thinks they’ve been inserted. Toothpicks will do just as well!

The article then lists several conditions for which, it is claimed, there is evidence that CAM is effective. The problem is that they’re not. Perhaps the most egregious examples are the claims that gingko biloba is effective for claudication (it’s not) and saw palmetto for prostatic hypertrophy (it doesn’t work). But this is the most disturbing thing in the article:

As for payment, Blackwelder said techniques such as OMT are supported with specific CPT codes and can be billed along with an appropriate evaluation and management service. Moreover, he added, if a physician spends more than half of a face-to-face visit of 25 minutes’ duration counseling a patient about various health issues and treatment options, including CAM techniques, he or she can code that visit as a 99214 — even in the absence of history, physical exam or medical decision-making elements.

The physicians reading this will know why this paragraph is so disturbing. According to my handy dandy CPT manual (2008 edition), CPT code 99214 involves:

Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components:

  • A detailed history
  • A detailed examination
  • Medical decision making of moderate complexity

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs.

Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family.

In other words, Blackwelder looks to be wrong, and all I had to do figure that out was to pick up my CPT manual off the shelf of my office and find the code. I worry that any physician who follows his advice about CAM and uses CPT code 99214 in the way Balckwelder advocates could easily find himself in a world of hurt, thanks to third party payers and in particular the federal government, the latter of which considers Medicare or Medicaid fraud to be a very serious offense. It also doesn’t always take ignorance of requirements for the various codes as an excuse. In fact, a physician I wonder whether a physician who makes the mistake of following Blackwelder’s advice with regards to billing Medicare could find himself in jail if he does it enough times. At the very least, it’s possible he could find himself in a whole heap o’ trouble with Medicare in terms of returning money and paying fines.

I’ve often discussed the corrosive effect that CAM has on medical academia, how it corrupts the very scientific basis of medicine. Unfortunately, it does more than that. As advocated by the AAFP, it can corrupt professional societies like the AAFP to the point where, not only does the AAFP advocate CAM quackery in the pages of its journal, but it publishes advice on its own website that could cause serious trouble for any of its members who follow it.